ACOG

Committee on
Obstetric Practice

Committee
Opinion
Number 326, December 2005

This document reflects emerging

clinical and scientific advances as
of the date issued and is subject to
change. The information should
not be construed as dictating an
exclusive course of treatment or
procedure to be followed.
Copyright December 2005
by the American College of
Obstetricians and Gynecologists.
All rights reserved. No part of this
publication may be reproduced,
stored in a retrieval system, posted on the Internet, or transmitted,
in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without prior written permission
from the publisher.
Requests for authorization to
make photocopies should be
directed to:
Copyright Clearance Center
222 Rosewood Drive
Danvers, MA 01923
(978) 750-8400

The American College of

Obstetricians and Gynecologists
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
12345/98765

Inappropriate use of the terms fetal

distress and birth asphyxia. ACOG
Committee Opinion No. 326. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:
146970.

VOL. 106, NO. 6, DECEMBER 2005

Inappropriate Use of the Terms Fetal

Distress and Birth Asphyxia
ABSTRACT: The Committee on Obstetric Practice is concerned about the
continued use of the term fetal distress as an antepartum or intrapartum
diagnosis and the term birth asphyxia as a neonatal diagnosis. The
Committee reaffirms that the term fetal distress is imprecise and nonspecific.
The communication between clinicians caring for the woman and those caring for her neonate is best served by replacing the term fetal distress with
nonreassuring fetal status, followed by a further description of findings
(eg, repetitive variable decelerations, fetal tachycardia or bradycardia, late
decelerations, or low biophysical profile). Also, the term birth asphyxia is a
nonspecific diagnosis and should not be used.

The Committee on Obstetric Practice is concerned about the continued use

of the term fetal distress as an antepartum or intrapartum diagnosis and the
term birth asphyxia as a neonatal diagnosis. The Committee reaffirms that
the term fetal distress is imprecise and nonspecific. The term has a low positive predictive value even in high-risk populations and often is associated
with an infant who is in good condition at birth as determined by the Apgar
score or umbilical cord blood gas analysis or both. The communication
between clinicians caring for the woman and those caring for her neonate is
best served by replacing the term fetal distress with nonreassuring fetal status, followed by a further description of findings (eg, repetitive variable
decelerations, fetal tachycardia or bradycardia, late decelerations, or low biophysical profile). Whereas in the past, the term fetal distress generally
referred to an ill fetus, nonreassuring fetal status describes the clinicians
interpretation of data regarding fetal status (ie, the clinician is not reassured
by the findings). This term acknowledges the imprecision inherent in the
interpretation of the data. Therefore, the diagnosis of nonreassuring fetal status can be consistent with the delivery of a vigorous neonate.
Because of the implications of the term fetal distress, its use may result
in inappropriate actions, such as an unnecessarily urgent delivery under general anesthesia. Fetal heart rate patterns or auscultatory findings should be
considered when the degree of urgency, mode of delivery, and type of anesthesia to be given are determined. Performing a cesarean delivery for a non-

OBSTETRICS & GYNECOLOGY

1469

reassuring fetal heart rate pattern does not necessarily preclude the use of regional anesthesia.
Since October 1, 1998, all inclusion terms
except metabolic acidemia have been removed
from the International Classification of Diseases
code for fetal distress. The Committee believes that
there should be uniformity in wording. The
International Classification of Diseases, Ninth
Revision, Clinical Modification code for fetal distress is based on fetal metabolic acidemia and
excludes abnormal fetal acidbase balance, abnormality in fetal heart rate or rhythm, fetal bradycardia, fetal tachycardia, and meconium in liquor.
The term birth asphyxia is a nonspecific diagnosis and should not be used. The Committee strongly
supports the criteria required to define an acute
intrapartum hypoxic event sufficient to cause cerebral palsy, as modified by the ACOG Task Force on
Neonatal Encephalopathy and Cerebral Palsy from
the template provided by the International Cerebral
Palsy Task Force (1) (Box 1).

Criteria to Define an Acute Intrapartum Hypoxic

Event as Sufficient to Cause Cerebral Palsy
1.1: Essential criteria (must meet all four)
1. Evidence of a metabolic acidosis in fetal umbilical
cord arterial blood obtained at delivery (pH <7 and
base deficit 12 mmol/L)
2. Early onset of severe or moderate neonatal
encephalopathy in infants born at 34 or more
weeks of gestation
3. Cerebral palsy of the spastic quadriplegic or dyskinetic type*
4. Exclusion of other identifiable etiologies, such as
trauma, coagulation disorders, infectious conditions, or genetic disorders
1.2: Criteria that collectively suggest an intrapartum
timing (within close proximity to labor and delivery, eg,
048 hours) but are nonspecific to asphyxial insults
1. A sentinel (signal) hypoxic event occurring immediately before or during labor
2. A sudden and sustained fetal bradycardia or the
absence of fetal heart rate variability in the presence of persistent, late, or variable decelerations,
usually after a hypoxic sentinel event when the
pattern was previously normal
3. Apgar scores of 03 beyond 5 minutes
4. Onset of multisystem involvement within 72 hours
of birth
5. Early imaging study showing evidence of acute
nonfocal cerebral abnormality
*Spastic quadriplegia and, less commonly, dyskinetic cerebral
palsy are the only types of cerebral palsy associated with acute
hypoxic intrapartum events. Spastic quadriplegia is not specific
to intrapartum hypoxia. Hemiparetic cerebral palsy, hemiplegic
cerebral palsy, spastic diplegia, and ataxia are unlikely to result
from acute intrapartum hypoxia (Nelson KB, Grether JK.
Potentially asphyxiating conditions and spastic cerebral palsy
in infants of normal birth weight. Am J Obstet Gynecol
1998;179:50713.).
Modified from MacLennan A. A template for defining a causal
relation between acute intrapartum events and cerebral palsy:
international consensus statement. BMJ 1999;319:10549.

References
1. American College of Obstetricians and Gynecologists and
American Academy of Pediatrics. Neonatal encephalopathy and cerebral palsy: defining the pathogenesis and
pathophysiology. Washington, DC: American College of
Obstetricians and Gynecologists; 2003.

1470

ACOG Committee Opinion

Inappropriate Use of Terms

OBSTETRICS & GYNECOLOGY